For Richer and Poorer: Disentangling the Association Between Income Inequality and Health
Truesdale, Beth C.
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AbstractPeople tend to be sicker and die younger in places with high economic inequality than in places with low economic inequality. This fact is widely accepted, but the reasons for the relationship are disputed, partly because it is difficult for researchers to agree about how various features of such places are causally related. It may be more useful to think not only of inequality but of “inequality regimes,” defined as constellations of mutually reinforcing attitudes, customs, and power structures that promote or constrain both economic inequality and other forms of inequality. I argue that we can make progress by stepping back from causal questions to investigate more deeply the reasons that inequality and health are negatively correlated. Focusing on inequality in U.S. states, I investigate questions about when, why, and for whom this relationship exists. These questions have often been implied by previous theories but have less often been addressed empirically.
When I address the “who” question, I find that the association between income inequality and poor self-reported health is strongest among lower-SES groups and almost disappears (but is not reversed) among high-SES groups. As a result, income- and education-related disparities in health are larger in states with higher income inequality. Although blacks in the U.S. tend to have worse health than whites at every income level, income inequality is more strongly related to poor health among whites than among blacks, perhaps because black individuals, on average, are exposed to more health hazards than whites, making the effects of additional hazards smaller. These results are robust to a wide variety of controls, consistent with theories that assume that living in a state with high income inequality is worst for the health of those closer to the bottom of the income distribution.
When I address the “when” question, I find that the association between income inequality and poor health is close to zero among adults ages 25 to 44, but is much stronger among adults ages 45 to 64. In addition, the negative association between income inequality at any age between birth and age 60 and self-reported health at a mean age of 65 was strongest for those who lived in more unequal states between ages 16 and 23 and weaker for those who only lived in such states at other ages. Taken together, these results suggest that any effects of income inequality are likely to be lagged, cumulative, and unfold over the life course.
When I address the “why” question, I find that broad measures of state income inequality are associated with poor health, but that income inequality at the very top of the distribution is not. Although a “snapshot” of a household’s income in the year before an individual reports his or her health explains a relatively small portion of the relationship between state-wide income inequality and state-wide health disparities between socioeconomic groups, lifetime income appears to explain a greater portion. The fact that states with higher income inequality tend to have lower absolute economic mobility is among the most promising explanations for the state-level relationship between income inequality and income-related disparities in health.
These findings are consistent with a life course narrative. States with high income inequality offer particular challenges for low-SES youth making the transition to adulthood. These challenges include lower high-school graduation rates, higher unemployment rates, and fewer jobs that offer less educated individuals the prospect of upward economic mobility. Such contexts seem to put lower-SES youth on a path toward both lower incomes and worse self-reported health as they grow older.
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